NYC Early Intervention Program Notice of IFSP Meeting

1 NYC Early Intervention Program Notice of IFSP Meeting _____ _____. Parent's Name Date _____. _____. Address Dear _____, As we discussed, an IFSP Meeting has been scheduled for your child. The IFSP. Meeting will be held on (date/time) _____ at (location) _____. As we also discussed, if available, please bring the following information to the Meeting : 1. Health insurance information;. 2. Social Security Numbers for you and your child;. If you do not have some of this information, services will still be authorized for your child and family. You have the following rights at the IFSP Meeting : 1.

2 You have the right to participate in the IFSP Meeting where the needs of your child and family are discussed and a service plan is developed. 2. You have the right to consent to or refuse to consent to any services recommended at the IFSP Meeting . If you give consent for services, you can withdraw it at any time. 3. You have the right to review and obtain copies of all records used for the Meeting . 4. You have the right to disagree with some parts of the IFSP and you may file a systems complaint or request mediation or an impartial hearing (due process). Please refer to A Parent's Guide to the Early Intervention Program if you need more information: 5.

3 If you request due process, all services in dispute must continue without change until after the mediation and/or impartial hearing is held. If the time or place listed above is not convenient for you or you have any additional questions, we can reschedule this Meeting . Please call me at (_____)_____ if you have any questions. Sincerely, _____ _____. Name Title Programa de Intervenci n Temprana de la Ciudad de New York Notificaci n de la Reuni n Individualizada de Servicios para la Familia _____ _____. Nombre de Padre Fecha _____. _____. Direcci n Estimado _____, Como acordamos anteriormente, una reuni n para desarrollar un plan de servicios individualizado para la familia (IFSP) ha sido programada para su ni o/a.

4 La reuni n se llevara a cabo el _____en _____. Como tambi n acordamos, si los tiene disponible, por favor traiga con usted la siguiente informaci n: 1. Informaci n sobre seguro medico 2. N meros de Seguro Social para usted y su ni o/a. Si no tiene esta informaci n, esto no impide que se le autoricen los servicios para su ni o y familia. Usted tiene los siguientes derechos en esta reuni n: 1. Tiene derecho de participar en la reuni n donde se hablara sobre las necesidades de su ni o/a y familia y se desarrollar un plan de servicios. 2. Tiene el derecho de dar su consentimiento o rehusar a dar su consentimiento a cualquiera de los servicios recomendados en la reuni n.

5 Si da su consentimiento, puede revocar ese consentimiento en cualquier momento. 3. Tiene el derecho a revisar y obtener copias de todos los documentos usados en esta reuni n. 4. Tiene el derecho de estar en desacuerdo con algunas partes del plan de servicios y puede pedir una mediaci n y/o una audiencia imparcial. Por favor refi rase a la Gu a para los Padres del Programa de Intervenci n Temprana si necesita mas informaci n: 5. Si pide una mediaci n y/o audiencia imparcial, todos los servicios que se disputan continuaran sin cambios hasta que la mediacion y/o audiencia imparcial se lleve a cabo.

6 Si el lugar o la hora de esta reuni n no son convenientes para usted o tiene preguntas adicionales, podemos cambiar la fecha. Por favor ll meme al _____ con sus preguntas. Sinceramente, _____ _____. Nombre Titulo IFSP FORMS. Child's Name: (Last) _____ (First) _____ IFSP Meeting held within INDIVIDUALIZED FAMILY SERVICE PLAN. EI #:_____ DOB: ____/ _____/ _____ 45 days? [ ] YES [ ] NO. IDENTIFYING INFORMATION (Page 1) (If no, verify reason for Today's Date: _____/ _____/ _____ Gender: [ ] M [ ] F delay on Transmittal Form). IFSP Meeting (check as appropriate): Interim Initial 6 month 12 Month 18 Month 24 Month 30 Month 36 Month Amended (If this is an Amendment Meeting , check amended and the IFSP period) Transition Conference Transition Plan (check the transition box and the IFSP period).

7 Date of Initial IFSP :_____/_____/_____ At initial IFSP, write effective dates: 6 Month Review: _____/_____/_____ Annual IFSP: _____/_____/_____. Mother's/Guardian's Name: _____ Father's/Guardian's Name:_____. Child's Address: _____Apt. # _____ Zip Code_____ Parents' Language: _____. (Street) (Borough/City). Home Phone #: (_____) _____Alternate Phone #: (_____) _____ Cell Phone #: (_____) _____. Is child in foster care: ( ) No ( ) Yes If yes, please fill out the following information: Foster Parent/Surrogate's Name: _____ Agency: _____ Caseworker's Name: _____. Agency Address: _____ Phone #: (_____)_____.

8 Fax # : (_____)_____. Ethnicity: Hispanic Not Hispanic Race: White Black Native American or Alaskan Asian Native Hawaiian/ Other Pacific Islander NOTE: More than one racial category can be checked. IFSP Participants: Print Name: Agency: Signature: Parent Legal Guardian Foster Parent _____. Early Intervention Official Designee _____. Initial SC Ongoing SC ID #: Phone #: ( ). Evaluator Interventionist Other _____. Health/ Medical Information Diagnosis: Medical Alerts: IFSP Page 1: Identifying Information 9/10. INDIVIDUALIZED FAMILY SERVICE PLAN (Page 2) Child's Name: (Last) _____ (First) _____.

9 CURRENT DEVELOPMENT, and FAMILY CONCERNS EI #:_____ DOB: ____/ _____/ _____Today's Date: ____/ _____/ ____. Concerns: What my (parent) concerns are: (Provide example(s) of how daily routines are affected/ when this concern is most noticeable to the parent/family.). Motor: Ability to get around- gross motor (ex: sitting, rolling, standing, crawling, walking), handling small objects- fine motor, sensory skills) hearing, vision. Parent Concern: I have no concerns in this area at this time. Parent is concerned about this area of development (provide examples): _____. _____. _____. _____. MDE Results: There are no concerns at this time; the child is developing typically in this domain.

10 The evaluation results indicate concerns (Concern in attached MDE Summary): Adaptive: Sucking, eating solid foods, drinking from a cup. Sleeping, dressing, toileting.). Parent Concern: I have no concerns in this area at this time. Parent is concerned about this area of development (provide examples): _____. _____. _____. _____. MDE Results: There are no concerns at this time; the child is developing typically in this domain. The evaluation results indicate concerns (Concern in attached MDE Summary): Communication: Understanding what is being said, using sounds, words or gestures to let others know what he/she needs.